Policy Research Working Paper 9220

Strengthening Public Health Systems

Policy Ideas from a Governance Perspective

Stuti KhemaniSarang Chaudhary

Thiago Scot

Development Economics Development Research GroupApril 2020

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Produced by the Research Support Team

Abstract

The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.

Policy Research Working Paper 9220

Public health systems that are capable of disease surveil-lance and action to prevent and manage outbreaks require trustworthy community-embedded public health workers who are empowered to undertake their tasks as profession-als. Economic theory on incentives and norms of agents tasked with performing activities that society cares about yield direct implications for how to recruit and manage frontline health workers to promote trustworthiness and professionalism. This paper provides novel evidence from a survey of public health workers in Bihar, India’s poorest

state, that supports the insights of economic theory and taken together yields ideas that can immediately be put to work in policy responses to the COVID-19 crisis. These ideas address problems of governance and trust that have bedeviled health policymakers. Managing the current and preventing future pandemics requires going beyond tech-nical health policies to the political institutions that shape incentives and norms of health workers tasked with imple-menting those policies.

This paper is a product of the Development Research Group, Development Economics. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp. The authors may be contacted at skhemani@worldbank.org.

Strengthening Public Health Systems:Policy Ideas from a Governance Perspective ∗

Stuti Khemani † Sarang Chaudhary ‡ Thiago Scot§

Keywords: politicians, bureaucrats, local government, health servicesJEL Codes: H1, H4, H75

∗We are grateful to James Habyarimana and Irfan Nooruddin for undertaking the survey through Georgetown Uni-versity, and their collaboration in designing it. We thank Shanta Devarajan, Quy-Toan Do, Irfan Nooruddin, Eva Paus,Sergio Schmukler and Adam Wagsta� for comments on this draft. We thank Hemant Pawar and the World Bank’s IndiaCountry Team for their insights and suggestions. We thank Dr. Sanjay Kumar in the Government of Bihar, and theADRI team of Dr. Shaibal Gupta, Dr. Prabhat Ghosh, and Dr. Sudhanshu Kumar for comments during the course of thiswork. We thank the Cicero team for implementing the survey, and especially Dhananjai Joshi and Ankita Barthwal. Wethank Nikhil Utture for excellent assistance with all aspects of the survey. We thank CARE’s team in Bihar, especiallyDr. Tanmay Mohapatra, for facilitating preliminary �eld tests of the survey instruments. We thank the Bill & MelindaGates Foundation for funding the survey, and Saachi Bhalla, Debarshi Bhattacharya, Santhosh Mathew, Nachiket Mor,Usha Tarigopula and Sandhya Venkateswaran for their previous comments during the survey work. Disclaimer: Theviews expressed are those of the authors and not necessarily of the World Bank, its Executive Directors, or the gov-ernments they represent. Comments are welcome and can be sent to the following email of the corresponding author:skhemani@worldbank.org.

†World Bank, Development Research Group. Corresponding author: skhemani@worldbank.org‡World Bank, Development Research Group. schaudhary3@worldbank.org§UC Berkeley Haas School of Business. thiago_scot@berkeley.edu

1 Introduction

The global spread of a coronavirus has led to renewed calls for greater investments in public

health systems around the world. Policymakers are being advised to increase public spending

on health to combat the disease as well as provide a �scal stimulus to the economy (Wolf,

2020). A previous disease outbreak, of Ebola, had led researchers to conclude then that public

health systems in poor countries need Community Health Workers (CHWs) as the frontline

health workers to prevent, detect and manage disease outbreaks (Miller et al, 2018; Lo et al,

2017; Moon et al, 2015). This is the workforce that can ultimately implement any public health

policy strategy advised by senior scientists and health professionals. Without the institution

of such a workforce the world remains at risk of not being able to e�ectively manage and

prevent disease outbreaks, especially those that originate in and spread from low capacity,

poor countries.

This paper provides new ideas for policymakers to invest in frontline public health work-

ers using economic theory of "principal-agent" relationships, in which one type of actor, the

agent, takes actions on behalf of another, the principal. Insights from economic theory are

supported by survey evidence from Bihar, the poorest state of India, a place which is repre-

sentative of the challenges involved in building capacity of public health systems in poor en-

vironments. These ideas are: to combine steady wage structures, as opposed to high-powered

incentives where salaries are conditioned on speci�c inputs or outputs of health workers, with

management to strengthen peer-to-peer monitoring and professional norms; and political en-

gagement of local leaders around public health. These ideas can immediately be put to work

in policy responses to the COVID-19 crisis and strengthen public health systems to prevent

future pandemics.

Policy-makers in poor countries, such as India, have typically relied on voluntary or quasi-

voluntary CHWs, rather than contracting CHWs to perform speci�ed tasks under a wage

structure. Any remuneration that is provided is typically incentivized on indicators of service

delivery, such as in the case of the Accredited Social Health Activists (ASHAs) in India who

receive payments when they bring pregnant women of their village to deliver babies in public

1

health centers (rather than at home, where institutional assistance for delivery is unavailable).

Incentive payments are also supported by a growing body of research which uses randomized

control trials (RCTs) to assess the impact of performance-based �nancing in the health sector

(Ahmed et al, 2019, provide a review). These RCTs have found consistent evidence of positive

impact on health facility quality indicators such as cleanliness and availability of medicines

and equipment, but mixed evidence on the medical content of care, utilization and health out-

comes. However, most RCTs are unable to disentangle how much of the impact is owing to

greater �nancing becoming available, in poor resource contexts, versus the incentives-based

design of providing that �nancing. Kandpal et al (2019) provide some of the �rst evidence on

this question through the evaluation of a World Bank project in Nigeria that enabled lessons

to be drawn about how to design the �nancing provided to health facilities. The �ndings

suggest no substantial di�erence in impact between the performance-based arm, which had

speci�c features of high-powered incentives, such as bonus payments to sta�, and the gen-

eral provision of �nancing to be used at the discretion of autonomous, decentralized health

facilities.

The push in economics research to examine incentives in public service delivery came from

the 2004 World Development Report, Making Services Work for Poor People (World Bank,

2004), which documented widespread absenteeism, a clear and measurable indicator of poor

performance, among public sector health workers and teachers in public schools, along with

more qualitative evidence which suggests that public service providers in poor countries are

not motivated to do their jobs well even when they are present at their facilities. Given this sta-

tus quo situation of poor performance and weak incentives (for example, in one study, Baner-

jee, Du�o and Glennerster, 2008, found that health workers face no sanctions when they are

absent from work), it is perhaps not surprising that when incentives are credibly strength-

ened, such as within an RCT, outcomes are better than the status quo of weak incentives.

These research studies also show that scaling-up what "worked" within the context of the

study into actual policy (such as, for example, routine application of sanctions for unexcused

absences) is di�cult and often runs into political problems (Muralidharan and Sundararaman,

2011; Banerjee, Du�o and Glennerster, 2008; Dhaliwal and Hanna, 2014).

2

This paper uses a synthesis of economic theory to challenge the prevailing policy regimes

that focus on high-powered incentives to deliver basic health services and o�ers new ideas

that have the potential of working more e�ectively to improve public health. First, the paper

draws upon Khemani (2019) and World Bank (2016) to summarize the insights from a synthesis

of economic theory of principal-agent relationships. Economic theory argues that optimal

contracts in complex organizations that are tasked with providing public goods could use

low-powered incentives (steady wages, job security), and rely on recruitment of intrinsically

motivated workers, as well as professional norms among peers to achieve high performance

or productivity.

Second, the paper provides evidence from a rich survey in Bihar on current health policies,

management practices, and incentives, beliefs and norms of health workers in the public sec-

tor. It shows how current management practices and the environment in which health work-

ers perform their tasks are the opposite of what economic theory would recommend.

Third, the paper discusses how this di�erence between economic theory and policy practice

can be rationalized and explained. We use available research on institutions to argue that

low trust and perverse expectations of behavior in the public sector, for rent-seeking rather

than service delivery, characterize institutions in poor places like Bihar. Because of these

institutions, reform leaders are reluctant to provide steady wages to new cadres of public

health workers because they do not trust that the additional �scal burden will yield signi�cant

results that are valued by the citizens who vote them into, or remove them from, o�ce.

Fourth, the paper shows how local politics in Bihar (as in other poor places of the world,

examined in World Bank, 2016) exhibit potential for change that policymakers could harness

to transition to institutions of greater trust, and stronger norms of performance in the public

health sector.

The paper concludes with outlining a set of policy ideas for reform leaders and international

partners to immediately put to use as they respond to the COVID-19 pandemic. Over time,

these ideas can contribute to addressing weaknesses in public health systems that has bedev-

iled national and global policymakers. Fixing di�cult problems like public health requires a

3

complex mix of policy instruments, going beyond health to institutions of governance and

trust. This paper aims to bring these complex ideas to the fore at a time when governments

are forced to contend with health systems, and international �nancing is being mobilized to

assist them. Projects to combat the new coronavirus outbreak should use the arguments pro-

vided in this paper to inform the design of those projects, and help developing countries move

beyond the crisis to establish the public institutions needed for health.

2 Insights froma synthesis of economic theory of principal-

agent relationships

Public health services–disease surveillance, actions and outreach to prevent and manage outbreaks–

involve signi�cant positive externalities, in the classic economic sense (Claesen et al, 2003).

Delivery of services in one local area or to one population group has bene�ts for all, while

service failures can lead to global spread of disease, as the world is currently experiencing

with a new coronavirus. These positive externalities constitute a case for public spending on

public health to address the theoretical under-investment by private actors and markets alone.

Furthermore, a case can be made for direct government provision of public health services,

rather than through subsidies to private providers, because of the need for systems that stay

vigilant in normal times, in the absence of any crisis or visible health need, and for the legiti-

macy to regulate citizen behaviors in the broader public interest. The power of regulation of

individual behavior in the public interest resides with the state. All countries thus have some

form of a state agency tasked with maintaining public health goals and enforcing health laws.

Economic theory lends itself to understanding how such state public health agencies should

be organized, how health workers should be recruited and managed to e�ectively deliver the

services needed for detecting, preventing, and mitigating disease outbreaks. The health pro-

fession has weighed-in on these questions in the aftermath of the Ebola outbreak in West

Africa, arguing for public investments in community health workers (CHWs) who are mem-

bers of the communities they serve. From the economic perspective, the value of community-

embedded public health workers can be traced to their informational advantage. As mem-

4

bers of the community they are likely to have greater information about who is falling sick,

whether there are suspicious clusters of disease, whether citizens are complying with health

regulations, etcetera, than temporary visits by health supervisors from outside the commu-

nity. As members of the community, CHWs may also have greater communication capacity

to win trust and compliance with public health regulations. The trade-o� with these intuitive

advantages of greater local information and communication capacity is the �scal burden of

keeping such health workers on the public payroll. For example, critics of bureaucracies in

the United States argue that federal workers are overpaid and underworked (Johnson and

Libecap, 1994). Countries have not invested in keeping a regular cadre of CHWs on the public

payroll probably because of competing needs for public funding and lower public valuation of

a task focused on prevention–the bene�ts of surveillance and public health regulations typ-

ically do not make headlines, and are not visible (Mani and Mukand, 2007), while the costs

of complying with regulations are all too palpable. Furthermore, in poor countries where

workers on the public payroll are viewed as having weak incentives and motivation to per-

form the tasks assigned to them, even reform oriented politicians are reluctant to spend scarce

public resources on hiring them. Evidence of widespread absenteeism among public sector

doctors and teachers, for example, provides clear indicators of weak incentives and motivation

(Chaudhury et al, 2006).

Weak incentives and motivation are arguably the bigger problem (Filmer and Wagsta�, 2020)1

The �scal burden can be reduced, or the "value for money" by keeping CHWs on the pub-

lic payroll can be increased by tasking CHWs with additional health functions, such as ma-

ternal and child health, and expanding coverage of primary health to those who cannot af-1Filmer and Wagsta� (2020) provide a recent review of the problem of quality in the delivery of health and

education services. They also report emerging insights from ongoing meta-analysis of the impact of di�erentpay-for-performance schemes on a variety of health indicators. They conclude that much more research isneeded on the impact of di�erent "blended" schemes that combine steady budgets to health or education facilities,or steady salaries to individual providers, with elements of pay-for-performance. In this paper we focus on thetheory and evidence for remunerating community health workers who get tasked with di�erent public healthgoals by senior policymakers. As we show below, the "blend" we argue for is to combine steady wages to CHWstasked with public health services with management practices in health bureaucracies and engagement of localpolitical leaders. We discuss how economic and game theory provide insights for how communication canbe targeted at bureaucratic and political institutions to strengthen peer-to-peer professional norms, and localpolictical support for, rather than hindrance of health workers. We too call for more research to evaluate impact,and experiment with di�erent policy designs, as policymakers take-up the ideas proposed here.

5

ford private providers. For example, medical research has found that neonatal care can be

improved and childhood disease mortality can be reduced in poor resource environments

through community-based interventions (Bang et al, 1990 and 1999). These health bene�ts

can improve economic outcomes, and thus �scal space in the future, through the channel

of greater human capital (Flabbi and Gatti, 2018). But, the health, human capital and eco-

nomic bene�ts of community-based interventions can only materialize if the frontline health

workers are motivated to perform their tasks well. Economic theory provides policy ideas

to improve the performance of frontline health workers, which can reduce the trade-o�s and

increase the payo�s from greater public spending on public health workers.

The performance of frontline public health workers can be examined within a series of in-

terdependent “principal-agent” problems in which one type of actor, the agent, takes actions

on behalf of, or at the behest of another, the principal. Public health policies are selected

and implemented by government agencies within the following principal-agent relationships

illustrated in Figure 1: (i) between citizens and political leaders, (ii) between political lead-

ers and public o�cials who lead government agencies, and (iii) between public o�cials and

frontline providers. This �gure also shows how popular development initiatives of citizen

engagement, to monitor frontline providers and participate in service delivery, �t into this

framework.

To illustrate in the health policy context of India, there are at least three cadres of workers

who are expected to live and work in the communities assigned to them to serve: the Auxiliary

Nurse Midwives (ANMs) who are supposed to provide primary and maternal health services

at the lowest tier of public clinics, the health sub-center; the Accredited Social Health Ac-

tivists (ASHAs) who could provide a range of services and are currently incentivized to shift

home-based child deliveries to medical institutions; and the Aanganwadi Workers (AWWs),

who are responsible for delivering early childhood development and nutrition programs that

have direct implications for child health. The ANMs, ASHAs and AWWs together organize

immunization drives and vaccinate children in rural India, for example. ANMs and ASHAs

are hired and managed by the Department of Health of state governments in India, and im-

6

mediately supervised by the Medical O�cer in Charge of Primary Health Centers at the level

of blocks, the lowest tier of state administration above the village or community. AWWs are

hired and managed by the Department of Women and Child Development. Health policy in

India mandates the constitution of a committee, the Village Health Sanitation and Nutrition

Committees (VHSNC) through which citizens can participate in monitoring and contributing

to health and nutrition services. The VHSNC is presided by the directly-elected head of local

government. Local politicians can thus play a role in monitoring and managing health work-

ers, even though the formal powers reside within the bureaucracy of state governments who

ultimately report to the state-level executive, the Chief Minister and her cabinet of ministers

under a parliamentary form of government. Elections to gain power over the state govern-

ment are vigorously contested in India, with frequent turnover of political parties in o�ce

(Nooruddin and Chhibber, 2008; Nooruddin and Simmons, 2015), thus completing the chain

to citizens and society as the ultimate principals illustrated in Figure 1.2

Frontline health workers are thus tasked with multiple and complex functions that could be

expanded as policymakers strive to prepare for more global outbreaks of new diseases. In

fact, India is mobilizing these workers to deploy non-pharmaceutical interventions (NPIs) in

its �rst line of defense against the new coronavirus (The Hindu, March 31, 2020)3. While other

complex organizations share the problem of motivating agents to perform multiple tasks that

are di�cult to monitor, agents in the public sector have more unique roles of serving the

public interest. Public health tasks and functions, like disease surveillance, testing, enforc-

ing compliance with NPI policies, have precisely these characteristics of serving the public

good. Furthermore, in normal times, these frontline health workers serve the children and

women whose families’ capacity is limited by budget and credit constraints, in addition to

any behavioral constraints imposed by poverty, lack of education, and social discrimination.

In addition to the "public good" nature of tasks that health workers are required to undertake,2The governance of CHWs in Africa can similarly be framed in this interdependent principal-agent frame-

work. A detailed analysis of these relationships in Uganda is provided in Habyarimana, Khemani and Scot (2018).The case of Brazil, examined in Rocha and Soares (2010) is described further below.

3India’s Ministry of Health announced online training of ANMs, ASHAs and AWWs,along with nurses and doctors, for the implementation of activities to combat the pandemic.https://www.thehindu.com/news/national/coronavirus-panel-formed-for-co-ordinated-research-and-development-activity/article31221310.ece

7

the structure of principal-agent relationships in the public sector is also quite di�erent from

those in other complex organizations outside government. Namely, the presence of multiple

principals with potentially con�icting interests, such as citizens belonging to di�erent socio-

economic groups with di�erent preferences and attitudes to the public sector, local politicians,

medical o�cers, district and state bureaucrats, state politicians. This is a particular feature

of public sector organizations, or government bureaucracies, that is examined in economic

principal-agent theory (Dixit, 2002).

Two insights emerge from the literature about how to structure principal agent relationships

in government bureaucracies when tasks are multiple and complex, and involve serving the

public interest4: 1. Reduced role of high-powered incentives and greater role for recruiting in-

trinsically motivated agents 2. Reduced role for top-down hierarchical monitoring and greater

role for autonomy and peer-to-peer professional norms

In practice, bureaucracies across the world tend to use �at and above-market wages, presum-

ably to attract public service motivated and talented workers (Finan, Olken and Pande, 2015).

In many striking cases, these arrangements also “work”. For example, the success of one of

the highest performing education systems in the world, the Finnish public education system,

has been attributed to the meritocratic recruitment of highly trained teachers, imbued with

strong professional norms, and autonomy in their classrooms (World Bank, 2018). Incentives

are also strong in that teacher salaries are high to be able to attract highly competent indi-

viduals into the profession, and teachers can be let go by school administrators (who also

exercise autonomy in how they manage schools). But incentives are not high powered in that

salary structures are �at rather than consisting of bonus components contingent on test scores

of students. The Republic of Korea’s high-performing education system shares with Finland

these characteristics of the management of public school teachers (World Bank, 2018)5 Greater

autonomy in public agencies is also found to be robustly associated with better outcomes in

the delivery of public investment projects in developing countries (Rasul and Rogger, 2017).6

4Following are some of the pioneering contributions: Tirole, 1994; Dewatripont et al., 1999; Francois, 2000;Dixit, 2002; Besley and Ghatak, 2005; Acemoglu et al., 2008; Alesina and Tabellini, 2007, 2008.

5Even though the Korean and Finnish systems diverge in their pedagogical approach, they are strikinglysimilar when it comes to management of teachers in public education bureaucracies.

6Peer-to-peer monitoring and social interaction also matters in private �rms (Ashraf and Bandiera, 2018,

8

Yet, a body of research on public service delivery in poor countries cautions against trusting

the intrinsic motivation of workers in the public sector, providing evidence of poor perfor-

mance, and perverse incentives and motivation (for rent-seeking rather than service delivery).

For example, one study found that doctors in India systematically under-perform in the public

sector compared to in their own private practice (Das et al., 2016). Other qualitative research

suggests that the problem of poor performance is likely to be widespread because bribery and

corruption are the norm in human resource management in the public health sector, weak-

ening incentives for good performance (La Forgia et al., 2015). Furthermore, the available

research suggests that powerful leaders at upper levels of the government hierarchy, who

wield formal power over the humble workers on the frontlines of the state, can be thwarted

in their attempts to exact accountability and performance from them. Banerjee, Du�o and

Glennerster (2008) and Dhaliwal and Hanna (2014) provide evidence that reformers who tried

to use new technology to monitor frontline health workers and strengthen their incentives

ultimately failed to implement or sustain these reforms.

The available research has focused on documenting evidence of weak incentives and low ac-

countability for service delivery in the public sector, and thence on evaluating interventions

targeted at strengthening incentives, such as making some part of pay conditional on perfor-

mance indicators (for example, Singh and Masters, 2017, for CHWs). But what is available is

barely scratching the surface of knowledge needed to help reform leaders think about how to

structure government bureaucracies and assign tasks to leverage intrinsic motivation and to

reduce reliance on high-powered incentives. Even when increasing the power of incentives

has been shown to “work”, the authors of those �ndings concede that implementing optimal

incentive contracts at scale can place signi�cant demands on state capacity (Muralidharan

and Sundararaman, 2011).

Finally, the logic of economic theory, and growing international evidence in support of it,

further suggests that politics casts a long shadow on culture in the bureaucracy and at the

frontlines (World Bank, 2004; Devarajan et al, 2015; World Bank, 2016; Khemani, 2019). For

provide a review). For example, Kandel and Lazear (1992) showed how di�erences in the observed managementpolicies of American versus Japanese �rms can be interpreted in economic theory as arising from di�erentialdegrees of team-work norms and social pressure among peers.

9

example, research has found that e�ective enfranchisement of poor voters has direct conse-

quences for the delivery of health services and improved health outcomes, while poor voters’

disenfranchisement, through vote buying, has the opposite e�ects (Fujiwara, 2015 and Khe-

mani, 2015). But these ideas about the role of politics and exploration of its policy implications

has not happened through RCTs for the simple reason that the suggested interventions are

more complicated than what is feasible in most RCTs. The interventions involve not only

changes in contract design (level of wages, whether high powered or not) which other RCTs

have undertaken (Dal Bo et al, 2013; Ashraf et al, 2014; Ashraf et al, 2015), but crucially, these

contract changes need to be combined with political and bureaucratic reforms if the insights

of economic theory are to be fully tested and exploited. Collaboration with policy-makers

who are willing to experiment with policy is hard enough for most RCTs, and compounded

in this case by the complexity and potential sensitivity of targeting bureaucratic management

culture and political contestation.

In the absence of opportunity to directly undertake a policy experiment suggested by eco-

nomic theory, and evaluate its impact to the standards of econometric rigor of other RCTs,

the research in Bihar we report on in this paper gathered descriptive data, through rich sur-

veys using innovative modules to measure the variables that economic theory suggests are

important (such as, intrinsic motivation, and peer norms). This survey provides evidence

of the mis-match between actual policy practice and the insights from economic theory and

o�ers ideas to policy makers to adopt a di�erent approach to strengthening health systems

using the current crisis as an opportunity.

3 Description of the survey in Bihar, India

The survey was undertaken in the state of Bihar in India between November 2018 and March

2019.7 Data were collected across di�erent layers of government jurisdictions within the

state–districts, blocks and village governments, known as Gram Panchayats (GPs)–and across

di�erent types of respondents–politicians, bureaucrats or public o�cials, frontline service7Data were collected in two phases– one at the village level, and one above the village at blocks and districts

10

providers–who share interdependent relationships while undertaking their tasks of deliver-

ing public health and nutrition services. In the �rst phase, data were gathered from village-

level respondents–Gram Panchayat (GP) politicians, frontline health and nutrition workers

(ASHAs, AWWs, and ANMs at health sub-centers), citizens and leaders of women’s Self Help

Groups (SHGs), an important social institution in this context. In the second phase, the survey

was implemented to block and district-level respondents.

3.1 Geography of the survey

Budget and implementation constraints required us to select a sample of districts rather than

covering all 38 districts of Bihar. At the same time, we needed a large sample to be represen-

tative of the diversity within the state, and allow us to capture some variation across district-

level institutional characteristics. These constraints led us to determine 16 as the number of

districts in which to undertake the survey. The purposive selection of which 16 study districts,

from among the 38 of Bihar is described in the sampling materials posted at the following web-

site, along with survey questionnaires and all results currently available at this stage of our

data analysis: https://sites.google.com/view/stutikhemani/public-health-systems-survey

Within each of the 16 districts, 4 blocks were selected using a random number generator, after

stratifying by proximity to the main railway line. Within each block, 4 Gram Panchayats (GPs)

were selected using a random number generator. However, in one block each in the districts of

Lakhisarai and Buxar, 3 GPs instead of 4 were selected because the sampling protocol required

a su�cient number of replacement respondents to be available, and these districts only had

3 GPs ful�lling the replacement requirement (more details in section on Respondents below).

This yields a sample of respondents drawn from 16 districts, 64 blocks from within those

districts, and 254 Gram Panchayats (GPs) from within those blocks. The sampled districts and

blocks are shown in Figure 2.

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3.2 Respondents of the survey

Following the framework in Figure 1, data were gathered from the following types of respon-

dents:

1. Citizens:

The citizen survey was aimed at respondents from 16 households residing in each GP

area. The survey �rm was provided with a list of respondents (with replacements)

drawn randomly from the electoral rolls available of all voting-age adults in Bihar’s

population. The target sample size is thus 4064 citizens (16 each from 254 GPs).

Within the category of citizens, the survey additionally targeted o�ce-bearing members

of women’s Self Help Groups (SHG) under a rural livelihoods program in Bihar known

as Jeevika. However, we had no lists available with names of SHG leaders of the village-

level organizations across GPs. In the absence of these lists, we relied on the survey �rm

to ensure that enumerator teams would identify SHG leaders during their �eld-work.

The data from SHG leaders that have been provided to us is thus subject to a greater

than usual caveat: the risk of whether the enumerator teams accurately identi�ed and

obtained interviews with the targeted SHG respondents. The instructions provided to

the survey teams was to ask the GP Mukhiya and other GP-level respondents (such as

the ANM, ASHA and AWW) about the GP-level federated organization of all the SHGs

across the GP’s communities to identify its President, Secretary and Treasurer. That is,

3 SHG leaders were targeted for each GP, for a total sample of 762 (3 each from 254 GPs)

SHG leaders.

2. Politicians:

• Village level:

– GP Mukhiya (or head of the elected village council; 1 per GP)

– Elected village councilors or Ward members: 3 per GP

– Candidates who contested the Mukhiya position in the last election of 2016,

12

but lost: 3 contenders per GP

Lists were provided to the survey teams of all incumbent Mukhiyas to be inter-

viewed, and a random selection (with replacement) of 3 Ward members and 3 can-

didates from among those who contested the previous GP elections of 2016.8 The

targeted sample size of GP politicians is thus 1778 (7 each from 254 GPs) respon-

dents.

• Block level:

– Elected head of block-level government (Panchayat Samiti Chairperson)

– Elected member of Panchayat Samiti: targeted to be the member who is on a

committee related to public health

– Member of Legislative Assembly (MLA, Bihar state) elected from the MLA

constituencies in our study area: approximately 1 per block (57 MLAs across

the 64 blocks of the study area)

The survey �rm was responsible for identifying the block-level politicians targeted

to be interviewed. The targeted sample size of Block-Panchayat (Panchayat Samiti)

elected members’ is 128 respondents (2 each from 64 blocks). The 57 MLAs across

the 64 blocks of the study area were also identi�ed by the survey �rm. However,

because of problems of reaching politicians at a time that was close to the 2019

elections in India, the survey �rm was able to complete interviews with only 39

MLAs (of the targeted 57) , and with 119 Panchayat Samiti members (of the targeted

128).

• District level:

– Member of Parliament (MP, national-level) elected from the MP constituencies

in our study area: approximately 1 per district

– Elected head of district-level government (Zilla Parishad Chairperson)8Across Bihar, on average, 12 candidates per GP contested the Mukhiya elections in 2016.

13

– Elected member of Zilla Parishad: targeted to be the member who is on a

committee related to public health

The survey �rm was responsible for identifying the MPs from constituencies within

the 16 study districts, and the 32 respondents of the District-Panchayat (Zilla Parishad).

Again, because of problems reaching political leaders at election time, the survey

�rm was able to interview only 9 MPs, and 28 Zilla Parishad members.

3. Bureaucrats:

The following district and block-level positions were identi�ed which have supervision

and management powers over frontline health service providers.

• Block level

– Block Medical O�cer (typically known as MOIC– Medical O�cer in Charge

of the Block-level Primary Health Center)

– Block Programme Manager of the National Health Mission (NHM)

– Block Programme O�cer of Reproductive and Child Health (RCH) and Im-

munization

– Block Community Mobilizer (Block-level supervisor of ASHAs)

• District level

– Civil Surgeon or Chief Medical O�cer (CMO)

– Additional (like a deputy) Chief Medical O�cer (ACMO)

– District Programme Manager of NHM

– District RCH and Immunization In-Charge

– District Community Mobilizer (District-level supervisor of ASHAs)

The survey �rm was responsible for identifying and interviewing the respondents hold-

ing these positions. The �nal data submitted by the survey �rm contains 293 respon-

14

dents in supervisory or management positions, including: 13 Civil Surgeons, 11 Chief

Medical O�cers (including 4 who were in Acting capacity), 23 Superintendents (in-

cluding 13 in Deputy or Acting capacity), 9 District Programme O�cers-NHM, 4 Dis-

trict RCH and Immunization In-charge, 7 District Community Mobilizers, 58 MOICs, 58

Acting Facility Incharge, 43 Block Program Managers-NHM, 29 Block RCH Programme

o�cers, and 35 Block Community Mobilizers.

4. Public providers of health services:

• Village level:

– ANM at village health sub-center

– ASHA

– AWW

The survey team was provided a list (with replacements) of 3 AWW workers to

interveiw per GP, for a targeted sample of 762 AWW respondents. We did not have

population lists of ASHAs and ANMs. Hence, the survey team was instructed to

ask the AWW respondents to identify the ASHAs and ANMs in their communities

within the GP. The survey teams were to pick 3 ASHAs and all available ANMs to

interview in a GP. We describe the shortfalls from these targeted numbers in the

data description further below.

• Block level:

– Doctors at Primary Health Centers (PHC)

– Nurses at PHCs

– ANMs at PHC

• District-level:

– Doctors at District Hospitals or equivalent

15

– Nurses at District Hospitals or equivalent

The survey team was provided with a list of randomly selected candidates for the above

categories of respondents for all the PHCs and higher-level health facilities (such as

District Hospitals) across the 64 blocks of the study area. However, the survey team

reports substantial di�culty in adhering to this list because the personnel were not

found at the health facilities. We describe the numbers of respondents that the survey

team was able to reach in the sections below, and highlight the fact that we were not

able to reach a random sample of providers appointed at these positions.

3.3 Description of the questionnaire

The questionnaires were designed to understand whether the characteristics or traits (such

as, public service motivation and integrity) of frontline health workers in the public health

system, and how they are managed by their supervisors within the bureaucracy, correspond

to the insights of economic theory discussed above. All of the questionnaires are posted at

https://sites.google.com/view/stutikhemani/public-health-systems-survey. Below we brie�y

summarize some of the novel aspects of the data.

The concepts of intrinsic motivation and social pressure among peers are at the heart of eco-

nomic theory of managing complex organizations tasked with delivering public goods, but

are very di�cult to measure. The di�culties arise not only because they are intangible and

subjective concepts which makes it hard for researchers to design the questions that would

go into a survey, but also because it is hard for respondents to understand and answer the

questions. In our extensive �eld-testing of these survey modules in Bihar we found that the

abstract nature of the questions made it di�cult for respondents to grasp what we were ask-

ing. For example, the module to measure "integrity" comes from literature in psychology and

aims to assess the extent of moral disengagement (Moore et al, 2012). In �eld testing these

questions in rural Bihar, we found that respondents struggled to understand what we were

asking. The very �rst question of this module, for example, asks respondents to indicate the

extent to which they agree or disagree with the statement "It is okay to spread rumors to de-

16

fend those you care about." In Bihar, respondents repeatedly asked for concrete examples to

understand this question, leading us down a path where the module might di�er signi�cantly

from how it is administered in other countries and contexts.

Furthermore, in any country or cultural context in which similar questions have been tried,

respondents tend to exhibit what is termed as "social desirability bias"– that is, to answer

some of the questions in ways which they think would win social approbation even if their

true responses would be otherwise. For example, a question like "are you very careful or

attentive when undertaking a task?" has been used to measure the personality trait of con-

scientiousness, but getting sincere responses to it is a problem, as evidenced by 100 percent

of some respondents in our survey saying they are always careful. As we analyzed the data,

we assessed whether/which questions worked as intended, to capture meaningful variation

across respondents (even though the "levels" are subject to desirability bias). We report all

our �ndings so that readers can reach their own interpretation and argue against the ones we

o�er. Part of the contribution of this work is methodological– �nding better ways to measure

these concepts, that may be crucial for strengthening public health systems, through trial and

error.

We follow an established practice in the growing literature measuring public service mo-

tivation and integrity of grouping di�erent sets of questions into indices. The underlying

questions in each of the indices created are summarized below.9

In this paper we focus on the following traits:

• All Surveys:

1. Integrity Index (8 questions): Questions on agreement or disagreement with

morally disengaged behavior (e.g. it’s OK to spread rumors to defend those you

care about or it’s no big deal to pass someone else’s work as your own).9All indices are created using Inverse Covariance Weighting (ICW) as described in Michael Anderson. "Mul-

tiple Inference and Gender Di�erences in the E�ects of Early Intervention: A Reevaluation of the Abecedarian,Perry Preschool and Early Training Projects. Journal of the American Statistical Association. December 2008,Vol. 103, No. 484. This is similar to Principal Component Analysis (PCA), but overweights variables that pro-vide "new information" (i.e. have lower covariance with other variables). All underlying data is coded such thathigher value of indices are "more positive" outcomes.

17

2. Public Sector Motivation index (8 questions): Questions on commitment to

serve the public, capacity to resolve con�ict among people, faith in government’s

role in improving society.

We developed a new module to understand the attitudes of health workers towards their

work, and group these questions into an index of professional identity and e�cacy:

• Public providers’ surveys:

Professional identity and e�cacy (5 items): whether respondent would have pre-

ferred another profession; whether feels a sense of inner pride/ful�llment when doing

their work; whether gets social status from being in the profession; whether feel they

can improve outcomes through their e�ort; whether they have to take permission for

every little thing.

Finally, we asked frontline health workers and their supervisors within the bureaucracy about

management culture. During the �eld work to develop the survey instruments, we learnt that

frontline health workers attend regular meetings with their supervisors at the block level. We

thus targeted the questions to understand management culture by speci�cally referencing the

types of issues that come-up in these regular meetings with supervisors. We start by reporting

these results.

4 Management and professional culture

Health workers in Bihar attend regular meetings with their supervisors, which provides an

opportunity to measure management and professional culture through survey questions tar-

geted at the content of these meetings. Among the lowest tier health workers–the ASHAs–94

percent report meeting with the ANM of the village health center, their immediate supervisor,

and 85 percent report meetings organized at the next level, by the Medical O�cer In-Charge

(MOIC) of the Block Primary Health Center, at least monthly. Similarly, 95 percent of ANMs

report regular meetings (at least monthly) convened by their supervisor (block-level MOIC).

In the survey of supervisors (Medical O�cers in Charge, Civil Surgeons, various programme

18

o�cers at the district and block levels, including those who supervise the AWWs under the

Women and Child Welfare department), 98 percent respond that they hold meetings at least

monthly with the sta� who work under their supervision.

Figure 3 shows that high rates of respondents across health cadres report that these meetings

involve "scoldings" and discussion of bad performance. Among the lowest tier of workers, the

ASHAs and AWWs, more than 77 percent report that meetings with supervisors involve scold-

ings. These numbers are even higher for the ANMs, more than 90 percent of whom report

that meetings consist of scoldings. In response to a module of questions asked about meet-

ings with their peers and supervisors, the ANMs report that issues about bad performance

are often raised– 48 percent respond "always", and 44 percent "sometimes"; only 8 percent

say "rarely" or "never". In contrast, when it comes to the question of how often good work

is praised or recognized, 47 percent of the ANMs respond "rarely" or "never". As many as 30

percent of ANMs say that their supervisors always scold people at meetings for bad perfor-

mance. Similar patterns are reported by higher-level cadres of health personnel interviewed

at block PHCs and district hospitals– there is bunching of respondents at "always" when asked

about discussion of bad performance and "scoldings" at meetings, and at "never" when asked

whether good work gets recognized or praised. A consistent picture is provided by supervisor

respondents at the block and district levels, as shown in Figure 4. Among these supervisors,

76 percent report that bad performance is always discussed at these meetings.

The dominance of concerns with poor performance at management meetings would be con-

sistent with the research evidence of high absenteeism and low performance among public

health workers in India (discussed and cited in the sections above). The problem of absen-

teeism, in particular, is something the survey teams encountered when attempting to inter-

view the ANMs who are supposed to be located at the village-level health sub-centers. Among

the 254 targeted GPs, 226 health sub-centers were found, and out of these, 145 sub-centers (or

64 percent) were closed. The survey teams were able to interview ANMs at the 81 open sub-

centers and located 28 others, resulting in an available sample of 109 ANMs, less than half of

the expected number. The problem of lack of availability of ANMs at the health sub-centers

19

is corroborated in responses by citizens and local politicians. When asked whether the ANM

is usually available at the health sub-center, 73 percent of both citizens and GP politicians re-

sponded "sometimes", "rarely", or "never". Our survey thus con�rms what was widely reported

during our �eldwork in Bihar–that village-level health sub-centers are often dysfunctional,

and ANMs are not usually available.10 In contrast to the responses of citizens and local politi-

cians, when the ASHAs and AWWs were asked this question about the availability of ANMs,

only 35 percent responded "sometimes", "rarely" or "never". This pattern is consistent with

reluctance on the part of health workers to speak ill of their peers. Other survey questions

targeted at asking health workers about their view of peers is likely to su�er from this same

reluctance to answer the question objectively. One such question posed to ANMs was to think

about all the ANMs they knew or had worked with and tell us out of those how many were

hardworking, and how many were honest. Among the ANMs who answered these questions,

80 percent indicated that all (100 percent) of the ANMs they know are hardworking, and 88

percent indicated that all (100 percent) are honest.

While the regular "scoldings" and discussion of problems of poor performance in management

meetings is consistent with the evidence of lack of availability of ANMs on the job, it also

suggests a vicious cycle of low expectations sustained by lack of trust among colleagues and

peers. This can feed a lack of professional motivation among health workers as we �nd in

responses to another module of questions on whether ANMs feel attached to their profession,

and a sense of e�cacy. Half of the ANMs respond that they agree it would have been better

if they had taken-up another profession (in contrast, only 16 percent of doctors respond that

they would have taken-up another profession).

Lack of professional agency or e�cacy is particularly demonstrated in responses to the fol-

lowing question: "Irrespective of my e�orts, the system will not allow health outcomes to im-

prove". Figure 5 shows that across health cadres, from the village level up to doctors in public

hospitals and health supervisors, more than 70 percent agree with this statement. Lack of

professional authority or discretion is evident in Figure 6, showing high rates of respondents10Interestingly, in this regard, when comparing responses of citizens, ASHAs, AWWs and politicians at the GP

level on the modules to measure norms and motivation, the ANM respondents stand-out as having the lowestmeasures on Integrity and Public Service Motivation, as reported further below.

20

across health cadres agreeing with the statement that "In my work, I have to take permission

for every little thing."

Supervisor responses are a useful source for understanding the extent to which the public

health system su�ers from low-e�ort norms. As mentioned earlier, questions posed to health

workers about their expectations of their peers–whether they think their peers are hardwork-

ing or honest–did not work well in eliciting objective views because respondents are reluctant

to speak ill of their peers. Indeed, even supervisors appear reluctant to report any problems:

80 percent of supervisor respondents say that 100 percent of the various cadres of health sta�

are both hard-working and honest. But, when we restrict attention to the 20 percent of super-

visor respondents whose answers are less than 100 percent, these supervisors are reporting

quite high rates of dishonesty and shirking among health workers. The average reported

shares of dishonest/shirking workers when we only look at the data from those supervisors

are: 36 percent of ANMs, 44 percent of Nurses, and 47 percent of Doctors.11

Health supervisors answer other pertinent questions in ways that suggest systemic problems:

44 percent say that good workers get transferred because others feel threatened by them;

80 percent say that irrespective of their e�orts, the system will not allow people’s health to

improve; 67 percent say they have to get permission for every little thing. Health supervi-

sors’ responses to these three questions related to professional e�cacy are thus similar to the

responses of health workers across the cadres, from the GP-level up.

Grouping the set of questions aimed at measuring attachment to the profession, and sense of

e�cacy into an index, we examine variation across frontline health workers. Table 1 reports

correlates of this variation.

To highlight a few interesting correlations: one, non-receipt of salary payments is negatively

correlated with the index of professional identity and e�cacy, and this correlation is statisti-

cally signi�cant for ANMs but not for ASHAs/AWWs.12 Two, those who report few opportu-11The ANMs here include those posted at PHCs, who may be performing signi�cantly better than the GP-level

ANMs).12The average ASHA and AWW reported that in the past year, they had not received the payments due to them

for six months of work. The average ANM reported that salary for three months of work had not been received.That is, the ANM reports lower delays in receiving renumeration compared to the lower tier community health

21

nities for interaction with peers during the regular meetings held at the block-level Primary

Health Center also report weaker professional identity and e�cacy. Three, those who report

that informal payments (bribes) are important to get desired transfers and promotions are

also likely to report weaker professional identity and e�cacy. Four, those who report that

politicians create di�culties for their work are also likely to report lower e�cacy or weaker

norms. All of these correlations are reasonably intuitive, and consistent with the importance

of management practices and political environment in shaping professional attitudes among

health workers.

Taken together, the pattern of survey responses across di�erent cadres of health workers and

their supervisors suggests that the public health system is stuck in an equilibrium of low ex-

pectations, low trust, and low performance. Across the board, health workers express a sense

of professional ine�cacy, that no matter how hard they try, the system will not allow health

outcomes to improve. Health workers think they are not recognized and empowered to per-

form; those who have any management power or authority think that health workers need

to be scolded and handled strongly to get them to perform. This equilibrium stands in stark

contrast to the recommendations that emerge from the logic of economic theory about how

to organize institutions that are tasked with delivering services with "public good" charac-

teristics. The next section discusses how such an equilibrium is consistent with a broader

literature examining the role of institutions in development.

5 Institutions of low trust and perverse expectations of

behavior in the public sector

Available research suggests that low trust and perverse expectations of behavior in the public

sector, for rent-seeking rather than service delivery, characterize institutions in poor places

like Bihar. Scholars of Bihar argue that the Indian caste system runs deep in the state, which

together with a historical legacy of feudal systems of land ownership creates persistent social

divisions and lack of trust across groups (Gupta, 1981).

workers.

22

Bihar’s institutions can also be understood within a broader macroeconomic story of what

explains why some countries are rich and others persistently poor. One body of work has

argued that European colonization established "extractive" institutions in the history of cur-

rently poor countries, and those historical institutions have persistent e�ects till today, ex-

plaining why some places are not able to su�ciently grow out of poverty or develop "inclu-

sive" political institutions that assure health and education for all (Acemoglu, Johnson and

Robinson, 2001 and 2002; ). These ideas are tested by Banerjee and Iyer (2005) and Iyer (2010)

by examining variation in institutions within India. They �nd that colonial institutions have

persistent e�ects on agricultural productivity and the delivery of public services. Bihar hap-

pens to be the state where the historical institutions used by Banerjee and Iyer (2005) and

Iyer (2010) show no within-state variation. All of Bihar was governed directly by the British

and through feudal land institutions during the colonial era, which are the institutions these

authors �nd correlated with low agricultural productivity and fewer public good provision in

current times (respectively), long after independence and land reforms.

However, the mechanisms of persistent impact remain shrouded in mystery. Research is also

lacking on why current formal institutions, such as competitive electoral institutions, courts,

police, which most states, including Bihar, possess, are not su�cient to overcome the burden

of history. Further, these explanations may be unsatisfying because they are so abstract, and

provide such little guidance of ways out of the problem. What precisely are "extractive" in-

stitutions, and why is to so hard to reverse them after the colonial powers are removed? It is

di�cult to argue that Bihar’s political institutions are not "inclusive", after decades of compet-

itive elections, turnover of political parties in o�ce, and rise of lower-caste political leaders,

on platforms of empowering the lower castes. Indeed, our survey data are consistent with

inclusive politics, uncovering quite astonishing rates of political aspiration, and sophisticated

political thinking among citizens in rural Bihar, across caste groups (discussed in the section

below).

Taking stock of the literature on institutions, two World Bank reports have argued that the

reason historical institutions have persistent e�ects is because they work through norms–

23

beliefs about how others are behaving– which are slow to change (World Bank, 2016; World

Bank, 2017). Political norms are de�ned as a subset of social norms, pertaining to beliefs about

how others are behaving in the sphere of politics and government. Political norms of behav-

ior — what citizens demand from the state, and how they expect others to be acting in the

public sector — can explain why well-intentioned reformers, in powerful political positions,

�nd it di�cult to institute change. To illustrate the argument13, prevalent political norms can

be characterized as follows. Rational expectation among “ordinary” (i.e. non-o�ce-bearing)

citizens is that other citizens will vote for politicians who share their identity or ideology,

and who provide targeted private bene�ts, even though, in equilibrium, the consequences are

harmful for everybody (since voting on the basis of identity and private bene�ts weakens po-

litical incentives to provide public goods). Of these ordinary citizens, among those who have

leadership or entrepreneurial qualities, who become contenders for political power (starting

from the village level, as local elections spread within countries across the political spectrum),

the rational expectation is that other contenders are entering the fray to seek private rents

from public resources. Among o�ce-bearing citizens, or state personnel, all the way from

high- and mid-level bureaucrats to frontline providers, the rational expectation is that their

peers do not care about doing their jobs well because there are few formal or informal (sanc-

tions) rewards for (bad) good performance. The service delivery organizations of the state

thus lack both incentives and non-pecuniary sources of motivation (such as peer pressure

and professional norms). When a reform leader tries suddenly to strengthen incentives in

this low- performance setting, those reforms are resisted and thwarted by well-organized in-

terest groups, such as unions of teachers and doctors, or other political opponents who seek

rents from the status quo.

Where even dynamic and motivated leaders �nd it hard to bring reforms is where success is

di�cult to deliver using their executive powers alone, and therefore, also harder for them to

take credit for and return to o�ce. These di�cult areas are human-resource intensive and

require sustained change in the day-to-day behavior of a large number of frontline person-

nel. It is also precisely in these human-personnel-intensive sectors of delivery that leaders13This section draws on Khemani (2019).

24

face a particularly di�cult political trade-o� — win elections by extending the patronage of

government jobs and deploying ideological instruments (such as by exploiting social animus

between groups on the basis of religion or ethnicity) versus strengthening bureaucratic insti-

tutions so that service providers are professionally motivated and routinely held accountable

without need for political intervention. Thachil (2011) and Chidambaram (2012), for example,

�nd that political parties with religious ideologies respond to citizen demand for health and

education by providing services through their party organizations outside of the state bureau-

cracy, in order to win citizens’ gratitude and their vote; but, these parties do not appear to

have su�cient incentives once in o�ce to institutionalize service delivery by de-linking it

from patronage or ideological politics.

In the language of game theory, persistent and systemic problems of low e�ort and low per-

formance in government agencies can be understood as the non-cooperative equilibrium of a

Prisoner’s Dilemma, supported by low expectations for cooperation (that is, non-cooperative

norms) among large numbers of players. Dixit (2018) describes this problem in the context

of widespread corruption. Although it would be bene�cial for society as a whole to reduce

corruption, society is instead stuck at high corruption levels because individuals believe that

engaging in corruption is the best they can do given how others are behaving. For example,

bureaucrats ask for bribes in order to provide public services, and citizens pay these bribes

because they believe that most others engage in bribery; if they refuse to pay the bribe, they

will get nothing, or worse, they may su�er retribution.

The sections below present evidence of forces of change that may be harnessed by policy-

makers to try to make public health spending more e�ective in strengthening public health.

6 Potential for harnessing local political contestation

Patterns in the data suggest that citizen demand for public health can be a force for political

change in favor of e�ective public health spending.

One, there is little evidence of "populist" demands from citizens, such as for cash, or subsidies,

25

without regard for the opportunity cost of public spending on health. A clear majority of

citizens respond that any additional public spending for their area be allocated to health and

nutrition services for their children rather than to cash transfers, job creation programs, or

roads (Table 2).14 On a simple question about price subsidies that we tried out–whether gov-

ernments should provide electricity for free– as many as 25 percent of respondents answered

no, without any quali�cation, while 34 percent quali�ed that subsidies could be targeted to

poor people. These responses from the average citizen respondent stand in contrast to the

responses from those who were identi�ed in the data as leaders of the village SHG–only 17

percent of SHG leaders answered no, and 52 percent answered with an unquali�ed yes, com-

pared to only 40 percent of citizens saying yes (Table 3).15 This pattern of citizen responses is

even more striking when compared with how the higher income and educated respondents,

such as doctors, in our sample answered this question. Among doctors, for example, 57 per-

cent answered with an unquali�ed yes, that governments should provide free electricity, with

only 6 percent saying no.

Citizen responses to another set of questions– on whether they would vote for a candidate

for village Mukhiya who o�ers inducements at the time of elections, such as a gift or cash in

exchange for votes–suggest a more sophisticated political way of thinking than one of gullible

or cynical voters who are easy prey to vote-buying strategies. Only 10 percent of citizens

answer that they would vote for the gift-giving or bribing candidate, with 89 percent saying

they would not. It is not easy to dismiss these responses as arising only from social desirability

bias because other respondents– those that are identi�ed in the data as leaders of the village

SHG, and the village ANMs–who may be equally subject to the possibility of such bias–are

twice as likely to respond voting for the bribing candidate (20 percent respond they would

vote for the bribing candidate). Furthermore, the pattern of responses to some follow-up

questions probing whether the respondent thinks the bribing candidate is more likely to win

elections, more likely to be corrupt, and more likely to get work done compared to candidates14https://www.brookings.edu/blog/future-development/2019/04/08/what-do-poor-people-think-about-

direct-cash-transfers/15The SHG responses are similar to the responses of women in the sample, suggesting that the di�erence may

be entirely due to gender. That is, we do not �nd that those women who belong to SHGs are less likely to demandfree electricity.

26

who do not bribe, provides a critical view of bribing candidates. Across all respondents–

the average citizen, the SHG leaders, and the ANMs–more than 75 percent respond that the

bribing candidate is more likely to be corrupt, and more than 80 percent respond that the

non-bribing candidate would get more work done. Even those who answered that they would

vote for the bribing candidate are more likely to respond that the bribing candidate is more

likely to be corrupt and less likely to get work done than a candidate who doesn’t bribe. This

pattern suggests that citizens may inherently dislike bribing candidates, but nevertheless be

compelled to vote for them for other reasons, such as if there is no choice (all candidates

bribe), or if the bribing candidate is more likely to win. In our data, those who respond that

they would vote for the bribing candidate also tend to respond that the bribing candidate is

more likely to win elections.

Two, citizens have political aspirations. When asked whether they would consider running

for political o�ce, as many as 31 percent of respondents answer "de�nitely". Even when

we restrict the sample to only the third for which the respondent is a woman, as many as

21 percent respond "de�nitely" compared to only 5 percent among those women who are

frontline public health workers. The average female respondent is only slightly less likely

than SHG leaders to report interest in running for o�ce (26 percent of SHG leaders answer

"de�nitely"). This reported interest in running for o�ce in our survey is consistent with the

large numbers of candidates actually observed in GP elections in Bihar, with more than 10 on

average contesting the Mukhiya position. Other states, such as Andhra Pradesh, in contrast,

have 2-3 candidates contesting on average (Afridi et al, 2018).

Of course, the motives behind these aspirations to run for political o�ce is unclear. On the one

hand, these high rates of reported interest in running for o�ce could be because holding local

political o�ce is lucrative, presenting opportunities to extract rents from state-funded public

program. Even without overtly corrupt motives, standing for local elections may be one way

to get an income earning position, in an economic environment where jobs are scarce. On the

other hand, these responses suggest a highly contestable local political market, with low bar-

riers to entry, which may enable public service motivated individuals to become local leaders.

27

State government policy-makers may be able to leverage this local political contestability to

address problems of implementation and delivery.16

Among those citizens who have already identi�ed themselves as political contenders–the in-

cumbent village politicians and those who contested for the Mukhiya (village head) position

in the previous election–the data show that these village politicians are distinct from other

village-level respondents (citizens, ANMs, ASHAs, AWWs, Self Help Group members) in hav-

ing higher measures of public service motivation and integrity. Figures 7 and 8 show the

cumulative distribution function (CDF) of the public service motivation and integrity indices

for di�erent categories of village-level respondents. The �gures show that village politicians

are distributed at higher measures of public service motivation and integrity, compared to

the distribution of other village-level respondents. This could be because politicians tend to

answer the questions related to these characteristics less sincerely, and hence these measures

may not be capturing real di�erences in public service motivation or integrity among local

politicians. We do �nd some evidence, however, that the public service motivation measure

among local politicians tends to be positively correlated with health service delivery reported

by citizens-that is, citizens are more likely to receive maternal and child health services in

villages where the average politician is measured as having higher public service motivation.

Table 4 shows that women are more likely to receive iron and folic acid, and food supple-

ments during pregnancy in villages where local politicians are measured as having higher

public service motivation. The last column of Table 4 shows that women are less likely to

report never receiving postnatal care in villages where politicians are measured as having

public service motivation. We note that not all our survey measures of access to maternal and

child health services are signi�cantly correlated with politicians’ public service motivation.

The purpose here is not to argue that we have identi�ed a variable–namely, politicians’ pub-

lic service motivation–as a key predictor of access to health services, but rather to furnish as

much evidence as possible on the potential of local political contestation to support the policy16Further evidence of low barriers to entry for local political leadership comes from politicians’ responses

to questions about their family political history. As many as 35 percent of incumbent Mukhiyas, 80 percent ofMukhiya contenders and 62 percent of Ward members report that no one in their family has ever held politicalo�ce. The majority of these politicians, including those who come from non-political families, report that theywould de�nitely run again for o�ce.

28

directions we propose under the current calls for urgent action.

7 Potential of frontline public health workers

Citizens report greater reliance on publicly provided preventive and promotive health services

than on curative health services. For example, in response to a question about how often they

use government health facilities when someone in the family falls ill, only 12 percent answer

"often", while 47 percent answer "rarely" or "never". This is consistent with the �ndings from

the work of Das et al (2016) that people in rural India tend to rely on private providers for

curative health care. In contrast, when women in the sub-sample of households who had

experienced a recent pregnancy (within the past 5 years) were asked which type of provider

gave them ante-natal care, 85 percent responded by indicating a public provider (the ASHA

and AWW are the most frequently cited); only 14 percent indicated a private sector provider.

This di�erence in the extent to which the public sector is used for preventive and promotive

rather than curative care is particularly large for poorer and less politically connected citizens.

Table 5 shows that respondents who are in positions of political power–elected politicians of

local government (the panchayats at the village, block and district levels), members of the

state legislative assembly (MLAs) and members of the national parliament (MPs)–are signif-

icantly more likely to use government clinics or hospitals for curative care needs. We are

unable to control for measures of income and assets because these questions were not asked

in the surveys of higher-level politicians owing to sensitivity issues and time constraints in

getting these powerful respondents to sit down for a survey. We hypothesize that the esti-

mated in�uence of political power in accessing curative care in government hospitals may be

even higher if we were to be able to control for income, since higher-level politicians would

tend to have higher incomes, and higher incomes are associated with greater use of expensive

private care facilities.

Among the di�erent frontline workers who could provide maternal and child health/nutrition

services–the ASHAs, the AWWs, and the village sub-center ANMs–citizens systematically re-

port much lower reliance on ANMs than on the quasi-volunteer workers (ASHAs and AWWs).

29

For example, when recently pregnant women in the sample were asked who they most relied

upon for advice during their pregnancy, 33 percent responded by indicating the ASHA, fol-

lowed by 28 percent indicating a family member (such as, their mother-in-law); only 5 percent

indicated a nurse or ANM. Similarly, only 5 percent of the women indicated the sub-center

nurse as the provider of ante-natal care, compared to 27 percent indicating the ASHA, and

43 percent indicating the AWW.17 In response to a question about where their last child was

delivered, only 27 percent of women indicated the health center (including both the village

sub-center and the block-level PHC, where the ANMs are the key personnel assisting with

child births), while 17 percent indicated a home-birth, 34 percent indicated the district hos-

pital, and 21 percent indicated private providers. Furthermore, 41 percent of citizens report

that the ANMs are rarely or never there to provide health services at the village sub-center,

while only 18 percent respond that the ANMs are often there.

Consistent with the evidence of lack of availability of ANMs, we �nd that our survey measures

of public service motivation and integrity are lower among ANMs than among other cadres

health workers. Figures 9 and 10 show that ANMs are distributed at lower levels of integrity

and motivation compared to the distribution of other cadres of health workers. This evidence

underscores the need for complementary reforms (in addition to increasing public spending

on frontline health workers) to address the problem of incentives and norms among frontline

health workers.

8 Potential of complementary communication campaigns

Theoretical analysis of how changes in norms come about points to a triggering role for polit-

ical contestation, and the leaders selected through it. Leaders can play this role as “prominent

agents” who signal a shift in beliefs among society at large (Acemoglu and Jackson, 2015).

Growing experience with political engagement and the learning that comes from it, such

as through frustration and indignation with bad outcomes, can create fertile conditions for17The AWWs may be regarded as a signi�cant source of ante-natal care because AWWs may be distributing

supplements like folic acid. In answering a question about access to iron folic acid, 40 percent indicated that itwas provided by the AWW.

30

change in political norms (Bidner and Francois, 2013). Recent theoretical developments on

the management of complex organizations generally, both in the private and public sectors,

is also pointing to the role of leaders in shaping organizational culture. For example, Akerlof

(2015, 2017) de�nes the concept of “legitimacy” of leaders in getting lower level personnel

to follow the organization’s objectives of their own accord, through peer-to-peer interaction,

without incentive payments and monitoring from the top.

In each of these theories of how changes in norms come about, information and communi-

cation that shift expectations about how others are behaving is the necessary element that

brings about change. In some models, the information is communicated through the types of

leaders that are selected (Acemoglu and Jackson, 2015). In others, information is gathered and

shared over time among citizens through the experience of political participation (Bidner and

Francois, 2013). In any problem where norms support a less than desirable outcome, shifting

to a new norm requires information sharing and communication among the actors to update

their beliefs about how others are behaving. The role of political leaders and processes of po-

litical participation as the channels for sharing information that shifts norms in public sector

agencies, is consistent with classic work on norms for collective action (Ostrom, 2000).

Using these theoretical insights, communication campaigns can be designed to harness the

potential of local political contestation in shifting norms towards the public good of public

health. Given available platforms of regular meetings among peers–as is the case in the de-

partment of health in Bihar–these meetings can also be an arena in which communication

strategies can be used to strengthen peer-to-peer pressure for professional norms.

Our survey included a detailed module asking about media consumption across all categories

of respondents. The primary purpose in designing these modules was to understand the con-

text and patterns of media consumption with an eye towards future communication inter-

ventions targeted at strengthening norms. There are two elements to consider in this regard:

one, which media are likely to provide local (versus national) news; and two, which media are

likely to be shared in common across respondents, so that communication about local mat-

ters can be expected to reach them all simultaneously. Put another way, to what extent are

31

di�erent types of respondents–the health workers, citizens, politicians–accessing completely

di�erent media outlets for news, versus converging on some common platforms?18

The following patterns emerge:

One, among the "middle/upper-class" (urban, educated, higher caste and income) respondents

in our survey–the district and block-level politicians, health supervisors, and doctors–98 per-

cent respond that they read newspapers regularly, and cite 4 Hindi newspapers as their favored

papers.

Two, Figure 11 shows that GP-level respondents–who are rural, lower caste, education and

income– are far less likely to report reading newspapers regularly (daily or 2-3 times a week).

However, there is considerable variation across di�erent types of respondents: while only 31

percent of citizens report reading newspapers regularly, 82 percent of ANMs and 58 percent

of GP politicians do so.

Three, Figure 12 shows GP-level responses to the question "Which medium do you rely on

most for news–newspapers, TV, radio, social media/internet?". Even though 82 percent of

ANMs report reading newspapers regularly, only about half of ANMs answer that newspapers

are their main source of news, with 44 percent citing TV. Similarly, 33 percent of GP politicians

cite newspapers as their main source, while 41 percent cite TV. (In fact, the middle/upper-

class respondents in point one, also split between TV and newspapers when answering this

question of the main media on which they rely for news).

Four, Figures 13, 14 and 15 together show that among those who regularly read newspapers,

there is much lower dispersion in which newspapers they read compared to a high degree

of fragmentation across di�erent TV stations of those who cite TV as their main source of

news. Those who read newspapers converge on the same 4 Hindi language dailies that are

local to Bihar. The TV channels on which there is some convergence across respondents, are

all national channels and therefore unlikely to focus on local news.18Segmentation of consumers across di�erent media markets is being analyzed in the United States as a source

of increasing political polarization and non-cooperative norms, because it allows people to select into so-called"echo-chambers" to con�rm their priors rather than seek common ground with others.

32

Five, the average citizen in rural areas is more likely to rely on national Hindi TV channels

for news rather than on local newspapers. Strikingly, SHG leaders report the lowest reliance

on or use of newspapers (around 11 percent), and much more on national TV (43 percent).

Citizens and SHG leaders thus appear to have little consumption of or access to local news

from established news outlets, relying on a variety of "other" informal sources, such as their

social networks.

Hindi newspapers emerge as the dominant media for local news that is shared across in�uen-

tial respondents (ANMs, GP politicians, and middle/upper-classes of respondents above the

GP). A communication campaign that seeks to shift views simultaneously, across health ser-

vice cadres (ANMS and their supervisors at the block and district level), GP politicians, and

the upper-classes of the state, would thus need to seriously consider the role of newspapers

as a commonly shared and established media. The existence of newspapers as the shared

platform for accessing news is suited to communicating evidence and complex information

that requires reading to digest. At the same time, buying time on national Hindi TV channels

to devote to Bihar-relevant and speci�c messages, would be an important complement, to

reach citizens and SHG leaders who do not read newspapers, and to re-enforce the messages

delivered through newspapers.

9 Conclusion: Outlining policy directions for public health

spending

The evidence provided here of a vicious cycle of low trust, perverse expectations, and poor

performance in public health systems should inform the design of investments in public health

that policymakers are poised to undertake. Designs that do not address the trust de�cit will

miss an opportunity to use economic theory and research to build trust in public institutions

at a time when it is urgently needed for public health. This paper has presented evidence

of potential forces of change in local politics and health bureaucracies that can be harnessed

by policymakers to establish a cadre of trustworthy and professional frontline public health

33

workers.19

This concluding section outlines policy directions that could be tailored to any context, as we

do for Bihar, for reform leaders and international partners to consider in their investments in

public health systems. The following three elements characterize these policy directions:

• Infuse messages into management meetings in health bureaucracies: the Bihar

survey found that across all cadres of health workers, there are regular meetings held

with district and block-level management (75 percent of sub-center ANMs say they have

weekly meetings; 86 percent of ASHAs say they have at least monthly meetings with

the MOIC at the Block PHC), and a signi�cant proportion of health workers are part of

WhatsApp groups (39 percent of village-ANMs and 52 percent of block-ANMs say they

belong to a health workers’ WhatsApp group.). Evidence-based messages about the

need for professionalism and motivated service delivery can be crafted for sharing at

meetings that are already happening organically and provide an institutionalized space

for strengthening peer-to-peer norms.20 In the Bihar and India context in particular, this

involves a radical shift away from the culture of "scoldings" and disciplining, towards

encouragement and recognition of health workers as professionals whose services are

urgently needed for the good of society.

• Newspaper and TV campaigns: Bihar provides a context in which readership of

Hindi-language daily newspapers provides a platform to share complex messages that

require reading and discussion among people. As discussed above, newspaper read-

ing is already happening as a way of �nding out local, Bihar-speci�c news, and thus

presents an organic platform that external agents can use to disseminate credible, data-

based messages. At the same time, the relative importance of TV viewing among the

poorer groups of respondents in villages suggests a role for inserting Bihar-speci�c in-19The survey on which this paper draws was designed to understand the management environment in which

health workers perform their tasks, and did not have scope to address the important area of professional training.We thank Hemant Pawar and the World Bank’s India country team for highlighting the need for better pre-service and in-service training of health workers. Our paper can be used to craft complementary governanceinterventions so that better trained health personnel are motivated to use their training for health impact.

20Contrast this against the lack of such institutionalized space for social accountability–86 percent of citizensrespond that they have never heard of a village committee on health and nutrition.

34

formation as sponsored programs or ads into national TV channels (the ones people

report watching). Such media campaigns are not only hypothesized to reduce rent-

seeking by village politicians, and strengthen local incentives for health services, but

also to strengthen the hands of state-level reform leaders to invest in a new or reju-

venated cadre of frontline health workers. Research suggests that public health issues

have not enjoyed political salience in India because of di�erentiated demands across

socio-economic classes. Upper and middle classes in urban India may lack pertinent

information about the value of public health systems in reaching poor households in

rural India. Campaigns deployed through the mainstream media in Bihar that reaches

citizens across these di�erent socio-economic classes can, potentially, enable reform

leaders to build political support for investing in frontline public health workers.

• New recruitment and steady wages to community-based public health profes-

sionals (but crucially, accompanied by the two communication campaigns above):

as reviewed above, the economics literature on managing principal-agent relationships

in the public sector suggests that there is considerable scope for improving bureaucratic

productivity by reducing reliance on incentives and strengthening intrinsic motivation

and professional norms. Yet, RCTs that focus on incentives alone, with no compara-

ble arm on strengthening professional norms, have captured the policy imagination, to

the detriment of trying out di�erent approaches with potential. Financing incentive

payments, as well as implementing them with �delity to the design, require consider-

able resources. In normal times, it would be of value to policymakers to test whether

lower cost management reforms can improve service delivery compared to implement-

ing high-powered incentives. In the current time of crisis, the arguments provided in

this paper support a leap of faith in recruiting, training, empowering and equipping

frontline health workers with steady wages. Investing in this cadre to manage and pre-

vent disease outbreaks in their communities, liaising with the higher-tier health system

as advised to do so by the global scienti�c and technical research community, is indis-

pensable. Doing so by taking the game of local politics and bureaucracy seriously into

account will increase the likelihood of success in �ghting the current and future health

35

crises.

The policy package described above is similar in spirit to what Brazilian Governors in the

state of Ceara adopted over 1987-1994, as they confronted a situation of poverty recently

made worse by a drought; some of the highest rates of infant mortality (102 deaths per 1,000)

in the world; and no functioning public health system. The Governors combined meritocratic

recruitment of a new cadre of public health workers with a blizzard of communication using

local radio, the dominant media to in�uence local politics and governance. Tendler and Freed-

heim (1994) provide a case study of how these steps built trust in the public health system and

dramatically turned around health outcomes in the state within a span of a few years. Infant

mortality fell by 36 percent and vaccination coverage increased from 25 to 90 percent. Perhaps

even more importantly, the Ceara model was scaled-up across Brazil as the country’s Family

Health Program (now called Family Health Strategy), relying on state-recruited community

health agents to deliver basic services targeted at poor households. Rochas and Soares (2010)

estimate that this program has been successful in improving health outcomes in poor areas.

More examples from other parts of the world are provided by Wagsta� and Claeson (2004)

of how professional norms in teams of health workers leads to better health outcomes in the

communities they serve. This paper has focused on leveraging theoretical and new empirical

research for ideas on how to bring about these professional norms in institutional contexts

where they are missing to start with.

Policymakers who are poised to increase public health spending to respond to the global

health and economic crises can immediately use the ideas presented in this paper. Fixing

di�cult problems like public health requires a complex mix of policy instruments, going be-

yond health to institutions of governance and trust. This paper aims to bring these complex

ideas to the fore at a time when international �nancing is being mobilized to strengthen public

health systems. Fast tracked health projects to combat the new coronavirus outbreak should

use the evidence provided in this paper when designing those projects, and help developing

countries move beyond the crisis to strengthening public institutions for health. The research

division of the World Bank stands ready to help in clarifying and tailoring the ideas for im-

36

plementation in speci�c contexts, along with evaluating its impact over time.

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11 Figures and Tables

Figure 1: Principal-Agent Relationships of Government

Source: World Bank (2016).

Figure 2: Map of Bihar.

Note: Sample districts are colored in red and sampled blocks, within sampled districts, colored in green.

42

Figure 3: Share of health sta� saying management meetings discuss bad performance andinvolve scoldings

Note: This �gure reports the share of health sta�, in each survey, stating always or sometimes bad perfor-mance is discussed (left panel) or supervisors scold workers (right panel).

Figure 4: Supervisor reports consistent with dominance of discussing bad performance inmeetings

Note: This �gure reports the distribution of supervisors’ responses about how often workers are rewarded(grey bars); how often they are formally reported (orange bars); and how often bad performance is discussed(blue bars).

43

Figure 5: Share who agree with: Irrespective of my e�orts, the system will not allow people’shealth outcomes to improve.

Note: This �gure reports the share of health workers, in each group, that fully agree or somewhat agree thatirrespective of their e�orts the system will not allow people’s health outcomes to improve.

Figure 6: Share who agree with: In my work, I have to take permission for every little thing.

Note: This �gure reports the share of health workers, in each group, that fully agree or somewhat agree thatin their line of work they have to take permission for every little thing.

44

0

.2

.4

.6

.8

1C

umul

ativ

e Pr

obab

ility

-4 -2 0 2 4Index Public Service Motivation

Citizens PoliticiansANM ASHA/AWWSHGs Mukhiya

Figure 7: Distribution of Public Service Motivation across Village Respondents

Note: This �gure reports the cumulative distribution functions (CDF) of the index of Public Service Motiva-tion for each respondents’ category.

45

0

.2

.4

.6

.8

1C

umul

ativ

e Pr

obab

ility

-4 -2 0 2 4Index Integrity

Citizens PoliticiansANM ASHA/AWWSHGs Mukhiya

Figure 8: Distribution of Integrity across Village Respondents

Note: This �gure reports the cumulative distribution functions (CDF) of the index of Integrity for eachrespondents’ category.

46

0

.2

.4

.6

.8

1C

umul

ativ

e Pr

obab

ility

-5 0 5 10Index Integrity

CHW ANM PHCANM Subc Staff NurseDoctor Supervisor

Figure 9: Distribution of Integrity across Health Worker Cadres

Note: This �gure reports the cumulative distribution functions (CDF) of the index of Integrity for eachrespondents’ category.

47

0

.2

.4

.6

.8

1C

umul

ativ

e Pr

obab

ility

-4 -2 0 2 4Index Public Service Motivation

CHW ANM PHCANM Subc Staff NurseDoctor Supervisor

Figure 10: Distribution of Public Service Motivation across Health Worker Cadres

Note: This �gure reports the cumulative distribution functions (CDF) of the index of Public Service Motiva-tion for each respondents’ category.

48

21.8

9.94.53.6

12.7

47.5

45.8

12.4

4.12.7

10.5

24.6

60.7

21.5

6.50.94.75.6

25.3

11.5

10.64.6

16.3

31.7

7.64.22.72.8

12.3

70.4

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

How often read newspaper?

Daily 2-3 times a weekOnce a week 2-3 times a monthRarely Never

Figure 11

Note: This �gure reports the distribution of responses, for each surveyed group, about how often they readthe newspapers.

49

23.1

32.6

11.2

12.9

20.2

33.2

40.7

5.98.9

11.2

40.2

43.9

1.911.22.8

23.8

49.6

4.710.0

11.9

10.5

42.8

6.5

10.8

29.5

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

Medium most used for news

Newspaper TV NewsRadio News Social Media/internetOther

Figure 12

Note: This �gure reports the distribution of responses, for each surveyed group, about which medium theyuse the most to access news.

50

27.4

16.6

5.94.52.8

42.7

32.9

29.3

6.67.51.7

21.9

48.0

23.0

10.0

11.02.06.0

33.4

20.9

7.25.32.5

30.7

19.9

6.62.52.04.1

64.9

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

Which is your favorite newspaper?

Dainik Jagran bihar HindustanPrabhat khabar Dainik Bhaskar BiharOther Doesn't read

Figure 13

Note: This �gure reports the distribution of responses, for each surveyed group, about which is their favoritenewspaper.

51

47.8

29.0

10.3

7.95.0

42.2

37.5

8.4

9.72.2

51.1

24.5

10.6

11.72.1

48.2

30.2

10.3

7.73.6

56.8

18.8

7.25.6

11.6

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

Which is your favorite newspaper? | Read Newspapers

Dainik Jagran bihar HindustanPrabhat khabar Dainik Bhaskar BiharOther

Figure 14

Note: This �gure reports the distribution of responses, for each surveyed group, about how often they readthe newspapers, conditional on responding they read some newspaper.

52

7.77.09.18.04.23.73.31.4

13.9

41.6

15.2

12.35.45.26.17.14.22.7

11.5

30.3

15.0

6.510.31.9

11.26.59.32.8

16.8

19.6

11.4

10.13.46.36.25.66.33.1

13.5

34.0

10.45.33.15.63.23.42.91.5

14.6

49.9

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

Which is your favorite TV channel for news?

AajTak ABP NewsDilliAajTak DD NewsZee News ETV Bihar - bhojpuriIndia News India TVOther Doesn't watch news on TV

Figure 15

Note: This �gure reports the distribution of responses, for each surveyed group, which is their favorite TVchannel for news.

53

13.3

12.0

15.6

13.8

7.26.35.62.5

23.8

21.7

17.6

7.77.58.7

10.26.13.9

16.5

18.6

8.1

12.82.3

14.0

8.1

11.63.5

20.9

17.3

15.3

5.29.69.38.49.64.7

20.5

20.7

10.66.2

11.26.46.75.93.1

29.1

020

4060

8010

0%

of t

otal

Citizens Politicians ANM ASHA/AWW SHG

Which is your favorite TV channel for news? | Watch news

AajTak ABP NewsDilliAajTak DD NewsZee News ETV Bihar - bhojpuriIndia News India TVOther

Figure 16

Note: This �gure reports the distribution of responses, for each surveyed group, which is their favorite TVchannel for news, conditional on watching news on TV.

54

Table 1: Determinants of Professional Identity and E�cacy

(1) (2) (3)

ASHA/AWW ANM Pooled

Demographics

Married 0.150 [0.139] -1.144 [0.807] 0.154 [0.134]

ST, ST or OBC -0.102 [0.110] -0.054 [0.230] -0.030 [0.098]

Age -0.000 [0.005] 0.012 [0.016] 0.000 [0.005]

Have ration card 0.019 [0.066] 0.045 [0.205] 0.014 [0.060]

Uses whatsapp -0.078 [0.095] 0.077 [0.196] -0.049 [0.085]

Asset Index (ICW) -0.049 [0.036] -0.047 [0.130] -0.055* [0.033]

Behavioral traits

Index Personality Traits -0.026 [0.052] -0.112 [0.146] -0.052 [0.051]

Index Integrity 0.055 [0.040] 0.136 [0.137] 0.070* [0.038]

Index Public Sector Motivation 0.033 [0.042] 0.107 [0.130] 0.033 [0.040]

Index Enterpreneurship 0.085* [0.043] 0.284* [0.146] 0.091** [0.042]

Supervisors & Peers

Job tenure in years -0.004 [0.008] -0.004 [0.011] 0.001 [0.007]

How many months of salary not received -0.014 [0.010] -0.091** [0.039] -0.019** [0.009]

ANM supervisor has good or very good management skills -0.024 [0.139] -0.465 [0.398] -0.006 [0.133]

Sometimes or always supervisor scold peers who don’t perform 0.056 [0.086] 0.057 [0.273] 0.099 [0.082]

Supervisor report employees who don’t work and they lose job -0.128* [0.075] -0.053 [0.194] -0.126* [0.069]

Sometime or always there is recognition for good work -0.014 [0.070] -0.043 [0.218] -0.021 [0.067]

Sometimes or always interact with peers in BPHC meetings 0.320** [0.143] 0.201 [0.291] 0.258** [0.119]

Quite a few or all ANM known are hardworking 0.252 [0.240] 1.102** [0.537] 0.242 [0.218]

Quite a few or all ANM known are honest -0.140 [0.278] 1.041** [0.465] -0.047 [0.252]

Share ANM colleagues hardworkers 0.267 [0.392] 0.764 [1.280] 0.414 [0.378]

Share ANM colleagues honest -0.039 [0.368] -2.026 [1.677] -0.170 [0.355]

Politics

Politicians often/sometimes create work di�culties -0.185** [0.082] -0.036 [0.237] -0.186** [0.076]

Politicians often/sometimes support work -0.076 [0.084] 0.083 [0.278] -0.045 [0.080]

Good workers transferred due others feel threatened -0.125* [0.066] 0.279 [0.235] -0.091 [0.062]

Work somewhat or often hampered by delay of funds release -0.016 [0.073] -0.229 [0.226] -0.025 [0.068]

Had to use money or connections to get job 0.054 [0.105] 0.084 [0.336] 0.078 [0.098]

Important to get transfer or promotion: political connections -0.080 [0.112] -0.258 [0.342] -0.153 [0.102]

Important to get transfer or promotion: informal payments -0.249** [0.108] 0.291 [0.314] -0.224** [0.101]

Important to get transfer or promotion: both -0.132 [0.120] 0.089 [0.427] -0.190* [0.111]

Constant -0.264 [0.452] 0.358 [1.617] -0.459 [0.425]

Observations 896 81 979

Distric FE Yes No Yes

R-Squared 0.452 0.420 0.434

Note: Ordinary Least Squares (OLS) regression estimates of the predictors of professional identity and e�cacy(dependent variable is the index) among frontline health workers. Robust standard errors in brackets (* p<0.1,** p<0.05, *** p <0.01)

55

Table 2: Preferences for Public Spending on Health vs Jobs, Cash or Roads

(1) (2) (3)

Health Over Jobs Health Over Cash Health Over Roads

Indicators for di�erent respondents (omitted category: citizens)

SHG -0.047** [0.022] -0.036** [0.017] 0.007 [0.018]

Contender for Mukhiya 0.049*** [0.018] 0.022* [0.013] 0.022 [0.016]

Ward Member 0.034** [0.018] -0.010 [0.014] 0.019 [0.016]

Mukhiya 0.048* [0.028] 0.034* [0.020] -0.005 [0.028]

Panchayat Samiti -0.090** [0.045] -0.016 [0.031] 0.117*** [0.024]

Zilla Parishad 0.083 [0.068] 0.105*** [0.010] 0.138*** [0.037]

MLA/MP -0.364*** [0.073] -0.110* [0.060] -0.037 [0.060]

CHW 0.101*** [0.016] 0.049*** [0.012] 0.050*** [0.014]

ANM Subcentre 0.063 [0.042] 0.023 [0.030] -0.012 [0.039]

ANM PHC 0.071*** [0.022] 0.016 [0.016] 0.117*** [0.015]

Sta� Nurse 0.051* [0.027] 0.047*** [0.017] 0.105*** [0.017]

Doctors 0.045* [0.024] 0.066*** [0.014] 0.105*** [0.019]

Supervisors -0.085*** [0.029] -0.006 [0.020] 0.096*** [0.019]

Media Access

Watch TV Daily 0.014 [0.010] 0.034*** [0.007] 0.065*** [0.009]

Receive Newspaper Daily 0.045*** [0.013] 0.009 [0.010] 0.001 [0.011]

Read Newspaper Daily 0.011 [0.014] 0.013 [0.010] -0.016 [0.012]

Rely on Newspaper for News 0.020* [0.011] 0.007 [0.008] 0.034*** [0.009]

Social Indicators

Male 0.058*** [0.013] 0.005 [0.010] -0.022* [0.011]

Married 0.026 [0.020] -0.017 [0.014] -0.008 [0.017]

Age -0.000 [0.000] -0.000 [0.000] 0.000 [0.000]

Muslim -0.009 [0.016] -0.057*** [0.014] -0.070*** [0.015]

Constant 0.648*** [0.025] 0.878*** [0.018] 0.794*** [0.023]

Observations 9247 9247 9247

R-Squared 0.023 0.018 0.032

Note: OLS estimates to compare the policy preferences (health vs. other uses of public spending) of di�erentrespondents to the preferences of citizens, who are the omitted category. Robust standard errors in brackets(* p<0.1, ** p<0.05, *** p <0.01)

56

Table 3: Respondents NOT Demanding Free Electricity and Loan Waivers

(1) (2)

No - Free Electricity No - Farming Loan Waivers

Indicators for di�erent respondents (omitted category: citizens)

SHG -0.036* [0.020] -0.036** [0.017]

Contender for Mukhiya 0.108*** [0.025] -0.001 [0.018]

Ward Member 0.058** [0.024] -0.025 [0.016]

Mukhiya 0.115*** [0.036] -0.016 [0.023]

Panchayat Samiti -0.235*** [0.030] 0.261*** [0.046]

Zilla Parishad -0.182*** [0.066] 0.172** [0.085]

MLA/MP -0.320*** [0.038] 0.087 [0.062]

CHW -0.002 [0.018] -0.037** [0.015]

ANM Subcentre 0.103* [0.057] 0.038 [0.049]

ANM PHC -0.072*** [0.023] 0.253*** [0.024]

Sta� Nurse -0.080*** [0.027] 0.254*** [0.030]

Doctors -0.297*** [0.020] 0.056** [0.025]

Supervisors -0.260*** [0.023] 0.058** [0.026]

Media Access

Watch TV Daily 0.088*** [0.012] 0.006 [0.010]

Receive Newspaper Daily 0.004 [0.016] 0.010 [0.013]

Read Newspaper Daily 0.031* [0.017] -0.024* [0.013]

Rely on Newspaper for News 0.007 [0.013] -0.008 [0.010]

Social Indicators

Male 0.073*** [0.014] 0.024* [0.012]

Married -0.014 [0.021] -0.014 [0.020]

Age 0.000 [0.000] 0.001** [0.000]

Muslim -0.047*** [0.018] -0.030*** [0.011]

Constant 0.194*** [0.029] 0.089*** [0.023]

Observations 9247 9247

R-Squared 0.043 0.042

Note: OLS estimates to compare the demand for Free Electricity and Loan Waivers among di�erent surveyrespondents to demand among citizens, who are the omitted category. Robust standard errors in brackets (*p<0.1, ** p<0.05, *** p <0.01)

57

Table 4: Services Received from Community Health Workers

(1) (2) (3)

IFA Received Mother Received Supp Food Never Received PNC

Selection traits : GP (Village) Politicians

Average PSM Index - GP Level 0.251*** [0.080] 0.097* [0.058] -0.089* [0.047]

Average Personality Index - GP Level -0.155* [0.089] 0.010 [0.065] 0.114** [0.045]

Average Integrity Index - GP Level -0.051 [0.068] -0.010 [0.054] 0.054 [0.039]

Average Enterpreneurship Index - GP Level 0.121* [0.072] 0.039 [0.057] -0.122*** [0.045]

Selection traits: Community Health Workers (CHW)

Average PSM Index - GP Level -0.137** [0.068] 0.077 [0.058] 0.008 [0.038]

Average Personality Index - GP Level 0.026 [0.078] -0.011 [0.061] 0.026 [0.041]

Average Integrity Index - GP Level -0.110* [0.063] -0.095** [0.046] 0.030 [0.032]

Average Enterpreneurship Index - GP Level 0.110* [0.062] -0.001 [0.064] -0.012 [0.034]

Average E�cacy Index - GP Level 0.074 [0.073] 0.046 [0.053] 0.025 [0.040]

Selection traits: Self Help Group (SHG) leaders

Average PSM Index - GP Level -0.029 [0.051] -0.020 [0.043] 0.046* [0.027]

Average Personality Index - GP Level 0.055 [0.069] 0.038 [0.054] -0.021 [0.034]

Average Integrity Index - GP Level 0.044 [0.068] 0.016 [0.039] 0.004 [0.027]

Average Enterpreneurship Index - GP Level -0.032 [0.055] 0.069* [0.039] 0.037 [0.028]

Political Competition

Working on health issues can help re-election -0.494** [0.225] 0.213 [0.161] 0.250** [0.101]

Would vote for candidate who bribes -0.013 [0.083] 0.119* [0.067] 0.015 [0.046]

Socio-economic Indicators

Have ration card 0.072 [0.076] -0.014 [0.059] -0.006 [0.038]

Asset Index (ICW) -0.026 [0.026] 0.010 [0.022] -0.014 [0.015]

SC/ST 0.267** [0.114] 0.125 [0.094] -0.086 [0.058]

OBC 0.118 [0.095] 0.093 [0.075] -0.052 [0.050]

Muslim -0.257** [0.105] -0.061 [0.081] 0.077 [0.062]

Below Primary 0.019 [0.117] 0.128 [0.083] 0.040 [0.063]

Below Secondary 0.066 [0.089] 0.021 [0.071] 0.003 [0.043]

Above Secondary -0.020 [0.093] -0.067 [0.070] -0.029 [0.046]

Above High -0.156 [0.119] -0.087 [0.098] -0.015 [0.053]

No of Adults 0.010 [0.016] 0.014 [0.011] -0.004 [0.008]

No of Kids -0.044*** [0.016] -0.019 [0.012] -0.003 [0.010]

Landless -0.064 [0.087] 0.053 [0.077] -0.072 [0.052]

Small Holder -0.253*** [0.092] 0.043 [0.084] -0.036 [0.054]

Low Expenditure -0.145 [0.096] -0.072 [0.088] -0.081 [0.055]

Medium Expenditure -0.002 [0.076] -0.006 [0.062] -0.068* [0.039]

Constant 0.758*** [0.184] 0.404*** [0.145] 0.465*** [0.116]

Observations 674 705 707

R-Squared 0.172 0.120 0.113

Note: OLS regressions estimating predictors of women reporting that they received Iron and Folic Acid,Supplementary Food during their pregnancy, and Never receiving Post Natal Care from Community healthworkers. All speci�cations include district �xed e�ects. Robust standard errors in brackets (* p<0.1, ** p<0.05,*** p <0.01) 58

Table 5: Use of Government Health Facilities for:

(1) (2)

Common Illnesses Hospitalization

Indicators for respondents in increasing order of political power (omitted category: citizens)

Contender for Mukhiya 0.035* [0.019] 0.025 [0.021]

Ward Member 0.095*** [0.018] 0.085*** [0.020]

Mukhiya 0.153*** [0.031] 0.061* [0.035]

Panchayat Samiti 0.389*** [0.042] 0.260*** [0.046]

Zilla Parishad 0.339*** [0.085] 0.262*** [0.094]

MLA/MP 0.335*** [0.066] 0.172** [0.074]

Socio-economic Indicators

Muslim 0.006 [0.019] 0.027 [0.021]

SC/ST 0.047** [0.019] 0.087*** [0.021]

OBC 0.058*** [0.016] 0.096*** [0.018]

Below Primary 0.014 [0.022] -0.013 [0.024]

Below Secondary -0.003 [0.016] 0.022 [0.018]

Above Secondary -0.000 [0.017] 0.004 [0.019]

Above High -0.030 [0.022] 0.007 [0.025]

Male 0.019 [0.012] 0.003 [0.014]

Age 0.001** [0.000] 0.002*** [0.001]

Constant 0.159*** [0.029] 0.239*** [0.032]

Observations 6345 6345

R-Squared 0.029 0.018

Note: OLS regressions to estimate di�erences among respondents with increasing political power, comparedto the omitted category of citizens, in accessing government health facilities for curative care. Robust stan-dard errors in brackets (* p<0.1, ** p<0.05, *** p <0.01)

59